Facilitators and Barriers of Community-Level Quality Improvement for Maternal and Newborn Health in Tanzania

Abstract

A quality improvement intervention for maternal and newborn health was carried out in southern Tanzania at the community level. It sought to improve health-seeking behaviors and uptake of community-level maternal and newborn health practices. A process evaluation populated using data primarily from in-depth interviews and focus group discussions with the intervention’s implementers was undertaken in four villages receiving the intervention to evaluate the intervention’s implementation, uncover facilitators and barriers of quality improvement, and highlight contextual factors that might have influenced implementation. Performance implementation scores were used to rank the villages. Identifying higher- and lower-performing villages highlighted key facilitators and barriers of community-level quality improvement related to support from local leaders, motivation through use of local quality improvement data, and regular education around quality improvement and maternal and newborn health. These findings can be taken formatively in the design of similar interventions in the future.

Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries

“…For policy makers and donors to be convinced by costing data, they must first be convinced of the benefits of what is being costed, and this has created a challenge for QI approaches generally. We have not presented data on the individual improvements achieved by the 29 improvement teams included in our study, which are similar to those observed by other community QI projects from several settings in sub-Saharan Africa 31–34 61–65. Immediate process outcomes of the QI approach we used included: improved supervision and integration of the community health programme to the health system, consensus building across levels of the health system on priority problems and improved data quality on critical health service areas—all of which have been shown to support improved performance of CTC providers 5 9 43 66 67.…”

“…Policy makers are beginning to question whether CTC providers can achieve equitable service quality at low cost 29. Evidence is growing for systematically incorporating quality improvement (QI) approaches into community health programmes in low-income and middle-income countries, especially in maternal and child health 30–34. These community-level approaches appear to have been successful in terms of improving the quality and equity of services, but there is limited information about costs or cost-effectiveness of implementation 32 34.…”

“…Evidence is growing for systematically incorporating quality improvement (QI) approaches into community health programmes in low-income and middle-income countries, especially in maternal and child health 30–34. These community-level approaches appear to have been successful in terms of improving the quality and equity of services, but there is limited information about costs or cost-effectiveness of implementation 32 34. This lack of financial data acts as a barrier to decision makers, who may perceive the financial and time costs of incorporating QI approaches to be high when compared with the urgency of further expanding coverage while under pressure to show progress towards UHC 35 36.…”

Harnessing the health systems strengthening potential of quality improvement using realist evaluation: an example from southern Tanzania

“…In prior QI interventions, it was clear that participants seeing improvements as a result of their own action was empowering ( Tancred, 2016 ; Tancred et al , 2017 , 2018 ). Many participants within EQUIP expressed that they were now in a position to make changes where they previously could not.…”

“…Second, available data on implementation of other relevant QI interventions were collated. We reviewed publications from the EQUIP intervention ( Tancred, 2016 ; Tancred et al , 2017 , 2018 ; Waiswa et al , 2017 ; Baker et al , 2018 ) (some of which were produced from extensive qualitative data from QI team members and mentors at the community, health facility and district levels) and other collaborative QI interventions with multi-level components in LMIC settings ( Singh et al , 2013 ; Cofie et al , 2014 ; Tesfaye et al , 2014 ; Kumar et al , 2019 ). From the EQUIP intervention, the following additional documents were reviewed: learning session minutes, mentoring and coaching records, and EQUIP project staff reports.…”